ticularly, pulmonary tuberculosis is often secondary to tuberculosis of the bronchial glands resulting from infection through the tonsils, and the earliest lesion is frequently found in the neighborhood of the hilum. Generally speaking, tubercle fórmation begins rather deeply and extends toward the periphery. When infection takes place primarily through the intestinal tract, the mesenteric glands are commonly first involved. It is reasonable to believe that autoreinfection may take place by the same route.

The chief factors in combating the lodgment and multiplication of bacteria in the body are the ciliated epithlial lining of the upper respiratory tract, the bactericilad action of the nasal mucosa and the gastric juice, and the phagocytic and antitoxic properties of the blood.

The pathologic unit of tuberculosis is the submiliary tubercles, minute nodules about 1-60 inch in diameter. Miliary tubercles are made up from ten to fifty of the smaller growths, and appear to the naked eye as gray, translucent bodies, the size of a pinhead or a hempseed, with a white center. They are nearly non-vascular, becoming dry, opaque, white or yellow caseous bodies. The presence of tubercles in the tissues may produce caseation, ulceration, sclerosis or calcification-one or more or all combined.

Tubercles are made up chiefly of a reticulum of cuboidal epitheloid cells with vesiculated nuclei. These cells are derived from parenchyma cells, from the endothelia of blood and lymph vessels, and the epithelia of serous membranes. Wandering leucocytes invade the connective tissue matrix, and constitute the lymphoid cells of the tubercles.

Large, composite "giant cells" are characteristic, though not pathognomonic, of tuberculosis. They may develop from epithelia or endothelia by incomplete segmentation, owing to deficient nutrition, the nuclei, but not the protoplasm, dividing. Their number is in inverse relation to the tubercle bacilli, which are commonly arranged within and around the margin of the "giant cell."

Dissolution of tubercles is nearly always due to secondary infection by pyogenic germs. Under favorable circumstances, the vascular zone surrounding the tubercle undergoes fibrous change, leading to cicatrization or encapsulation of the caseous, or better

still, the calcified nodule. On the other hand, when the agminated masses of round cells and bacilli are large, they are liable, by confluence, through cutting off nutrition, to undergo coagulation necrosis and eventually caseation, forming the so-called tubercular abscesses, which, on evacuation through a bronchus, leave cavities. These are lined with a layer of necrosed caseous tubercular material, bounded externally by a wall of granulation tissue and lymphoid elements. Cavities are sometimes traversed by more or less corroded blood-vessels or bronchioles.

Quiescent, or "healed in," tubercles are those in which the tubercular process has been self-limited by the development of a dense fibrous boundary wall, in which is retained the more solid caseous detritus or calcareous mass, still including as a rule potential bacilli, which may break forth again with virulence under favoring conditions.

The so-called pretubercular stage corresponds with the period of eruption of tubercles before the appearance in the sputa of tubercle bacilli, which may be absent for months in the incipient, or even an advanced stage of the disease. They can be present in the expectoration only when there is free communication between the softened tubercular focus and the bronchial apparatus. A few bacilli alternating with large numbers may be due to the occasional opening and evacuation of large cavities. The clumping of granular bacilli indicates a tendency to breaking down of tissues and formation of cavities.

Tubercular deposits take place first as a rule and most abundantly at the tip of the lung, along its borders and posterior aspect. When infection is direct, by the air passages, a bronchopneumonic and lobular tuberculosis is set up, followed by caseation of inflammatory products, and terminating either in clerosis with limitation of morbid products, or in dissemination by lymph and blood when the connective tissue is exposed by breaking down of the intervening wall.

The extension of the tubercular process may be slow or rapid, steady or intermittent. The disease is often widely disseminated before any subjective symptoms are noted. When it has extended so as to involve a whole lobe, the symptoms often ameliorate, and the so-called latent stage of arrested tuberculosis supervenes. In favorable instances a case of advanced phthisis may also enter on

a quiescent stage after the discharge, absorption or inspiration of the abscess contents, or when formed cavities become clean and dry. Usually, however, the tendency is to successive eruptions of tubercles during or soon succeeding excavation.

Phthisis, in a strictly pathologic sense, does not begin until the caseous tubercles commence to soften and break down. Acute diseases occurring during a latent tuberculosis are frequently followed by phthisis, since they check the natural encapsulating process of cure and set up liquefactive changes.

Toward the fatal end of phthisis the pathologic changes may include a variety of lesions, such as miliary tuberculosis; caseous, fibroid and calcareous degeneration; pneumonic infiltration; bronchial catarrh and ulceration; areas softening into excavations; and open and closed cavities in all stages of inflammation, ulceration and cicatrization.

The common associated changes of chronic ulcerative phthisis are catarrhal pneumonia, broncho pneumonia, purulent bronchial catarrh and pleuritis, and proliferation of the interstitial connective tissue. Pneumonias from mixed infection are markedly severe, causing a rapid advance of the tubercular disease and early decline. Tubercular children are particularly liable to attacks of localized pneumonia around the tubercular area.

The acute miliary, pneumonic and bronchopneumonic types, the ordinary caseous tuberculosis (chronic ulcerative phthisis), and the chronic fibroid form of the disease, represent, generally speaking, different degrees of infection and of individual resistance and reaction.

EDITORIAL ITEMS.

Idiopathic Amenorrhea.-Bushong recomends manganese binoxid in pill form in the dose of one to four grains three times a day.

Menopausal Menorrhagia.-Fordyce Barker employed rectal suppositories of 3 1-3 grains of aqueous extract of ergot thrice daily, for a week previous to the return of the expected period.

Menorrhagia of Chronic Endomertitis.-Thorough curettage often affects a cure. H. A. Davidson recommends local galvanization, with the positive pole in the uterus.

Tachycardia of Arteriosclerosis.-Vires (Medical Press) gives two grains of extract of convallaria and one grain of sparteine sulphate daily in pills.

Sudden Suppression of Menses from Chill.-Ringer recommends tincture of aconite, one drop every half hour or hour.

Uterine Hemorrhage for Pelvic Congestion.-In some cases, says Hare, dry cups over the sacrum give relief.

Menorrhagia from Atony of Uterus.-Potter prescribes one grain of extract of ergot and one-half grain extract of opium every hour for profuse menstruation.

American Medical.—The next meeting of the American Medical Association will be held at New Orleans May 5th, 6th, 7th and 8th, 1903.

The Presbyterian Hospital of Philadelphia has received a gift of $30,000 from an anonymous donor for the purpose of building a new maternity house.

Respiration. Guenther states that it may easily be calculated that man in 24 hours respires about 10,800 litres of air, which is equal to a space 7.1-3 feet in three dimensions.

Menorrhagia of Systemic Origin.-When occurring in young subjects, Hare advises potassium bromide, five or ten grains night and morning for a week before expected period.

Myomatous Metrorrhagia. According to Brickner, the fluid extract of hydrastis candensis three or four times a day, controls irregular bleeding as a rule without resort to further measures.

Amenorrhea of Obesity.-Lustand prescribes a cachet twice or thrice daily containing 11⁄2 grains aloes and 1⁄2 grain each of rue, savin and saffron.

Editorial Items continued on Page 466

BOOKS.

LEA'S SERIES OF MEDICAL EPITOMES.

MANTON'S ORSTETRICS_

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